Objectives. To demonstrate the usefulness of an effective and timely information model, underscore the seriousness of the problem of homicides, and point out the need to apply this type of model as well as comprehensive prevention projects, such as Desarrollo, Seguridad y Paz (DESESPAZ). From 1993 to 1998, 11 457 homicides were registered in Cali, Colombia, through an epidemiological surveillance model established under DESESPAZ by the mayor's office in Cali. Methods. Beginning in January 1993, a work group organized by DESESPAZ reviewed and standardized the variables that different institutions gathered about the victims, their assailants, and the facts surrounding each case, and issued a weekly summary bulletin for the mayor and other local authorities. Results. Between 1983 and 1994, the homicide rate increased from 23 to 124 per 100 000 inhabitants. Subsequently, rates went down in 1995, 1996, and 1997 to 112, 102, and 86,1 per 100 000, respectively, and again rose slightly in 1998 to 88 per 100 000. Even though people of all ages, including children under 5, have been victims of violence, the most affected group is that of men between the ages of 20 and 34. The ratio of men to women has varied from 14.3:1 to 9.2:1. In terms of numbers, percentages, and rates, low-income groups are the most seriously affected, although the highest-income groups have had rates as high as 160 per 100 000. A firearm was used in over 80% of homicides, and the crime was most often committed at night and on a weekend. A suspect was identified in only a few cases (8% to 21%). The bivariate analysis revealed a positive association with alcohol consumption by the victim, as well as with the use of firearms by the assailant (OR: 3.1; 95% CI: 2.6 to 3.6). Cases that occurred during a fight between individuals or during group fighting showed an association with the use of a sharp weapon and with alcohol consumption by the victim (OR: 1.9; 95% CI: 1.4 to 2.6). Conclusions. A map shows the homicide distribution by neighborhood, and the benefits of a population-based surveillance model are discussed, particularly their usefulness for identifying risk factors and the measures that can be applied to prevent and control this form of violence.

An evaluation of the adverse reaction potential of three measles-mumps-rubella combination vaccines Articles

Objective. To compare the incidence of adverse events following the administration of three commercially available measles-mumps-rubella (MMR) combination vaccines. Methods. A randomized double-blind clinical trial was performed in 1996 that involved a total of 10 142 students 6-12 years of age in the state of Rio Grande do Sul, in Brazil. An MMR vaccine containing the Edmonston-Zagreb, Leningrad-Zagreb, and RA 27/3 strains ("vaccine A") was administered to 2 226 students (21.9% of the total); an MMR vaccine with the Moraten, Jeryl Lynn, and Wistar 27/3 strains ("vaccine B") was administered to 2 216 children (21.8%); and an MMR vaccine containing the Schwartz, Urabe AM-9, and Wistar 27/3 strains ("vaccine C") was given to 2 179 students (21.5%). A control group of 3 521 students (34.7%) was not vaccinated. Both the vaccinated subjects and the control subjects were followed daily for 30 days to detect any clinical manifestations. Results. Adverse events were more frequent in the vaccinated children than in the control group (P < 0.01). In terms of causing parotitis, vaccine A had a relative risk (RR) of 5.72 (95% confidence interval (CI) = 3.11-10.54) when compared with vaccine B, and an RR of 2.33 (95% CI = 1.52-3.58) when compared with vaccine C. Vaccine A was also associated with an increased risk of lymphadenopathy when compared with vaccine B (RR = 3.11; 95% CI = 1.78-5.45) and with vaccine C (RR = 2.22; 95% CI = 1.35-3.66). Vaccine C was associated with an increased risk of parotitis when compared with vaccine B (RR = 2.46; 95% CI = 1.26-4.80). Three cases of aseptic meningitis were detected among the children in the study group, but only one case of vaccine-related aseptic meningitis was identified, among the children receiving vaccine A. Conclusions. The three MMR vaccines that we studied are associated with different risks of adverse events. We found vaccine A to cause more reactions than the two other vaccines, especially vaccine B. In addition, vaccine A presented both a temporal and a cause-and-effect association with one case of aseptic meningitis. We hope that this study will contribute information that can be used in choosing MMR vaccines with safe and effective strains, especially for mass vaccination strategies.

Primary and booster vaccination with DTPw-HB/Hib pentavalent vaccine in Costa Rican children who had received a birth dose of hepatitis B vaccine Articles

Objective. The DTPw-HB/Hib pentavalent combination vaccine has been developed following recommendations of the World Health Organization for the introduction of hepatitis B (HB) and Haemophilus influenzae type b (Hib) vaccines into routine childhood vaccination programs. The objectives of this study were to: 1) analyze the immunogenicity and the reactogenicity of the DTPw-HB/Hib pentavalent combination vaccine in comparison to separate injections of DTPw-HB and Hib vaccines as primary vaccination in a group of children who had received a dose of HB vaccine at birth and 2) in the second year of life to assess the antibody persistence as well as the response to a DTPw-HB/Hib or DTPw/Hib booster. Methods. In the first part of the study (primary-vaccination stage), conducted in 1998-1999, we analyzed the immunogenicity and reactogenicity of the DTPw-HB/Hib combination vaccine in comparison to separate injections of DTPw-HB and Hib vaccines as primary vaccination at 2, 4, and 6 months of age in 207 Costa Rican children who had received a dose of HB vaccine at birth. Later, in the booster-vaccination stage of the study, in 1999-2000, in a subset of the children (69 toddlers, now 15-18 months old), antibody persistence was measured, and response to a DTPw-HB/Hib or DTPw/Hib booster was also assessed. Results. In both primary-vaccination groups, at least 97.5% of the infants reached protective levels of antibodies (seropositivity) against the antigens employed in the vaccines. The DTPw-HB/Hib pentavalent combination vaccine did not result in more local reactions than did the DTPw-HB vaccine alone, and, in terms of general reactions, there was no clinically significant difference between the combination or separate injections, and with the pentavalent vaccine having the benefit of needing one less injection. Nine months after the third dose of the primary-vaccination course, antibody persistence was similar in both groups, with over 93% of children still having protective/seropositive titers for Hib, HB, and tetanus and about 50% for diphtheria and Bordetella pertussis. At 15 months of age, virtually all the toddlers responded with a strong boost response to all the vaccine antigens, whether they received the DTPw-HB/Hib pentavalent vaccine or the DTPw/Hib vaccine as a booster. Both booster regimens were equally well tolerated, indicating that up to five doses of the HB vaccine can be given without impact on safety. Conclusions. Our study confirms that the DTPw-HB/Hib pentavalent vaccine is highly immunogenic as a primary vaccination in children who received an HB vaccine at birth, with the pentavalent combination inducing both persisting immunity and boostable memory. The pentavalent vaccine was safe both for primary and booster vaccinations. Thus, this study in Costa Rican infants supports the routine use of the pentavalent DTPw-HB/Hib vaccine as part of childhood vaccination programs in Latin America and the Caribbean.

Clinical and laboratory features of aseptic meningitis associated with measles-mumps-rubella vaccine

Objective. To describe epidemiological, clinical, and cerebrospinal fluid (CSF) findings in cases of aseptic meningitis associated with measles-mumps-rubella vaccination following a mass immunization campaign in the Brazilian state of Bahia in August 1997 promoted by the country's Ministry of Health, and to compare these cases to the cases of aseptic meningitis not associated with the vaccine that occurred in the same year. Methods. Between March 1997 and October 1997, all individuals between 1 and 12 years of age admitted to the Couto Maia Hospital (the Bahia reference hospital for infectious illnesses) with a clinical and laboratory diagnosis of aseptic meningitis were prospectively followed. The study population was divided into two groups: one with individuals who had received the vaccine, and one with individuals who had not received the vaccine. Demographic, clinical, and laboratory information was collected on both groups. Results. In September, following the vaccination campaign, 74 cases of aseptic meningitis were registered at the Couto Maia Hospital, versus the monthly average of 7.5 cases. We observed a greater frequency of nuchal rigidity and increased CSF cellularity among children whose meningitis was associated with the vaccine. However, encephalitic involvement was more frequent in the group of children with non-vaccinal meningitis. Conclusions. Although the course of post-vaccinal meningitis is more benign than that of other forms of the disease, its treatment generates costs related to ancillary exams and hospitalizations. Mass vaccination campaigns should employ less reactogenic vaccine strains.

Premature death from infectious diseases in Spain, 1908-1995 Artículos

Objectives. Infectious diseases have traditionally been one of the leading causes of death in developed countries. The objectives of this research were to: 1) quantify the importance of infectious diseases as a cause of premature mortality in Spain between 1908 and 1995, and 2) determine the frequency and distribution of the infectious diseases with the greatest impact on premature death. Methods. The study was carried out based on data on mortality from infectious causes published by the National Institute of Statistics in the Movimiento natural de la población (Natural Movement of the Population) for the study period. Three indicators of premature mortality were used: the potential years of life lost (PYLL), the crude rate of PYLL per 1 000 population, and the percentage and the average of PYLL. Results. Between 1908 and 1995, the number and the rate of PYLL from infectious causes clearly declined. The decrease was more prominent starting in the 1950s, and it was seen in all age groups. Tuberculosis was the leading cause of premature death from the beginning of the century until the 1970s, but after that, the leading causes became pneumonia and AIDS. Conclusions. The impact of infectious diseases as determinants of premature death in Spain declined during the 20th century, especially starting in the 1970s.

Objective. To determine if there is an unrecognized problem of congenital rubella syndrome (CRS) in Haiti, a country without a national rubella immunization program. Methods. During March 2001 and June 2001, screening physicals were conducted on approximately 80 orphans at three orphanages in Haiti that accept disabled children. Children were classified as probable CRS cases based on established clinical criteria. Photo documentation of findings was obtained whenever possible. Results. Six children met the criteria for probable CRS. Using data from surrounding Caribbean countries and from the United States of America prior to rubella immunization, we estimated that there are between 163 and 440 new cases of CRS per year in Haiti. Conclusions. CRS exists in Haiti, but its presence is generally unrecognized. A national rubella immunization policy should be considered.

Screening for colorectal cancer Temas de Actualidad

This piece summarizes new recommendations from the Preventive Services Task Force of the United States of America concerning screening for colorectal cancer (CRC). These recommendations update and replace ones that were issued in 1996. The Task Force strongly recommends that physicians carry out CRC screening tests for both men and women who are 50 years of age or older. The Task Force found fair or good evidence that: 1) several screening methods are effective in reducing mortality from CRC, 2) the benefits of screening outweigh its risks, although the quality of the tests, the magnitude of the benefits, and the potential harms vary according to the method, and 3) periodic fecal occult blood testing (FOBT) reduces mortality from CRC. In addition, there is fair evidence that sigmoidoscopy, either alone or in combination with FOBT, reduces CRC mortality. There is no direct evidence that screening colonoscopy is effective in reducing CRC mortality, nor is it clear if the greater accuracy of colonoscopy in comparison to other tests compensates for its additional complications, inconvenience, and costs. Double-contrast barium enema is less sensitive than colonoscopy, and there is no direct evidence that it is effective in lowering mortality rates. There are insufficient data to determine which screening strategy is best in terms of the balance of benefits, potential harms, and cost-effectiveness. Regardless of the strategy chosen, CRC screening is likely to be cost-effective (less than US$ 30 000 per year of life gained).